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or in the oesophagus itself, and the symptom has been regarded as dysphagia rather than vomiting.

VIII. Acute peritonitis, especially when the gastric peritoneum is involved, is often accompanied with severe vomiting. The statement has been made that it does not take place in acute peritonitis unless the peritoneum in the neighbourhood of the stomach is implicated; but although this is generally true, it is not constantly the case. Chronic peritonitis is also a cause of vomiting; so also local peritonitis and effusion near the stomach. In some of these instances the stomach is affected by its direct implication in the disease; in others vomiting arises from the pressure of effused pus, or the constriction of adhesions.

IX. Pressure on the stomach is a direct cause of vomiting. In ascites and ovarian disease the stomach is sometimes so compressed that vomiting comes on soon after food has been taken, apparently from this cause alone; and when paracentesis has been performed, the pressure being removed, the sickness ceases. When glandular tumours in the neighbourhood of the pancreas, or disease of the pancreas itself, exert pressure on the stomach the symptoms closely resemble primary disease of the stomach, and the diagnosis is exceedingly difficult; but, since the pancreas receives a branch from the pneumogastric nerve, it is not easy to ascertain how far vomiting, in some of these cases, is due to nervous irritation, and how far it is due to direct pressure. In

those cases in which the pancreas has been diseased without great enlargement, and without pressure on the stomach or duodenum, I have not observed that vomiting is a prominent symptom. In aneurismal disease of the abdomen, the remark which we have made in reference to disease of the pancreas and its glands holds good; and the same difficulty arises in determining how far the vomiting is due to pressure, or to sympathetic irritation.

In some cases we have found direct pressure made by the patient at the scrobiculus cordis the cause of vomiting; and in an instance of a boy, some years ago, in Guy's Hospital, it was only after very careful watching, that the true character of the complaint and the deceit of the patient were ascertained.

X. As to vomiting not depending on the condition of the stomach itself, we have to refer to morbid states of other abdominal viscera; and first, to disease of the duodenum, as inflammation of its mucous membrane, ulceration, and especially obstruction.

There is great similarity between the diseased conditions of the first portion of the duodenum and of the stomach. A form of dyspepsia, in which vomiting, with pain at the seat of the duodenum, comes on at the close of digestion has been attributed to the duodenum ; but whether this class of cases is connected with an abnormal irritability of the pylorus itself, we cannot affirm. Again, in some cases of acute jaundice, febrile

symptoms with violent irritability of the stomach arise without pain; and the disease has been attributed to mischief commencing in the duodenum, and extending to the biliary ducts. In some fatal cases of this kind, great congestion in the duodenum has tended to confirm the idea, so also the fact that symptoms of this kind have come on after intemperance.

Ulceration of the 1st portion of the duodenum produces many of the symptoms of like disease in the stomach.

XI. In hernia, obstructive disease of the intestines, intussusception, &c., vomiting is generally present. If the obstruction be in the small intestine, the vomiting comes on very quickly; but if the colon, sigmoid flexure, or rectum be the seat of the disease, vomiting is often postponed for a considerable time, unless irritant medicines and violent purgatives have been administered. As the vomiting continues, the ejected matters present the character of the fluids at the seat of obstruction; and, if that obstruction be intestinal, their odour and appearance have more or less of a fœcal character.

XII. The regurgitation of food, which is consequent on disease of the pharynx, larynx, or œsophagus must be distinguished from actual vomiting. By carefully observing the process of deglutition, the seat of mischief may be accurately ascertained. In paralysis of the muscles of the soft palate, and of the pharynx, deglu

tition cannot be properly completed, and food is rejected through the nares; so also when the epiglottis is ulcerated from strumous, syphilitic or cancerous disease, the act of deglutition is scarcely performed before the substance swallowed is violently ejected, and severe pain in the throat, and cough are set up. It is remarkable too, in these cases, how a solid bolus of food may be formed and swallowed, slipping beyond the diseased surface; whilst the smallest quantity of fluid produces most violent pain and distress.

In obstruction of the oesophagus the act of deglutition is completed, and then regurgitation takes place. Very extensive disease may, however, affect the oesophagus without this rejection of food; for ulceration or sloughing may have removed obstruction, or the branches of the pneumogastric nerve and the whole wall of the canal may be destroyed.

Other causes of vomiting are expressions of the general and intimate connections of the stomach; they are properly designated sympathetic in their relationship, and their study is of essential importance in the diagnosis of disease of the stomach. As with the previously mentioned causes of vomiting we shall do little more than enumerate them, and the first of this class to which we shall allude is,

XIII. Disease of the liver and of the gall bladder. Large branches of the pneumogastric nerve extend to the liver, as well as numerous nerves from the large

sympathetic ganglia. In gall stone, violent vomiting is generally associated with intense pain; and in many conditions of hepatic disease irritability of the stomach is a frequent symptom.

XIV. In disease of the supra-renal capsule—Addison's disease-vomiting is rarely absent; but sometimes it is a sign of such prominence as to simulate primary disease of the stomach. On post-mortem examination we have found arborescent injection of the mucous membrane of the stomach, and sometimes slight ulceration; but it must also be remembered, that the pneumogastric nerve affords a branch to the supra-renal capsule, and that its connection with the semi-lunar ganglia is a very intimate one.

XV. Diseases of the kidneys and renal calculus constitute other causes of vomiting. During the passage of a calculus down the ureter vomiting is a very distressing symptom. In acute albuminuria vomiting is also associated with nausea; and in chronic albuminuria it is sometimes the precursor of a fatal termination. So severe, indeed, may be this symptom in ischuria renalis, as even to suggest the possibility of intestinal obstruction, as shown by Dr. Barlow. The vomiting in albuminuria is not only due to the direct connection of the nerves constituting the renal plexus, with those of the stomach, but to the urea excreted from the mucous membrane of the stomach and intestines. It is found to be present in large quantity in

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